Provider Demographics
NPI:1508961095
Name:NICKELS, TERRY LEE (DO)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:LEE
Last Name:NICKELS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95165
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73143-5165
Mailing Address - Country:US
Mailing Address - Phone:405-672-1316
Mailing Address - Fax:405-670-2477
Practice Address - Street 1:2803 SE 44TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73129-8533
Practice Address - Country:US
Practice Address - Phone:405-672-1316
Practice Address - Fax:405-670-2477
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK1706207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE09767Medicare UPIN